Deactivation of Admitting Diagnosis Code Edit


In 2019, CMS determined it was not consistently following the NUBC Manual guidance concerning the requirement of an admitting diagnosis code on Type of Bill (TOB) 18x (Hospital Swing Beds—Inpatient), 21x (Skilled Nursing Facility-Inpatient), and 41x (Religious Non-Medical Health Care Institutions--Inpatient) for Medicare fee-for-service claims (see MLN Matters Number: MM11307). As a result, on January 6, 2020, an edit was implemented in Medicare FFS systems and propagated to the Medicare Advantage front-end processing system to reject institutional encounter data records with the TOBs listed above that did not contain an admitting diagnosis code. The rejections occurred at the 277CA level of processing and returned an edit code of A6:>CSSC 232.  Upon review of this edit, CMS decided to deactivate this front-end edit for both encounter data records and chart review records. The edit was deactivated as of April 30, 2020. MAOs may resubmit previously submitted encounter data that were rejected with edit A6:>CSSC 232.

Last Updated: 05/12/2020